Synagis Copay Assistance Program^†

*Is the patient covered by commercial insurance coverage?

*Does the patient reside in the United States or Puerto Rico?

*Will any of the patients prescription claims be reimbursed, in whole or in part, by any state or federal government program, including, but not limited to Medicaid, Medicare, Medigap Department of Defense (DoD), Veterans Affairs (VA), TRICARE, Puerto Rico Government Insurance, or any state patient or pharmaceutical assistance program?

Patient Privacy Authorization
* I authorize my child's doctor(s), healthcare providers, health plan or payer, and pharmacies to use and to disclose to Sobi Inc. ("Sobi") and its third party suppliers, vendors, and other service providers supporting Synagis Connect (collectively, the "Service Providers") information about my child (for example, my child's name, address, insurance policy number, and income) and medical condition (for example, diagnosis or medications) (together, "Protected Health Information and/or Personally Identifiable Information"). This Personally Identifiable Information can include spoken or written facts about my child's health and insurance benefits. It can include copies of records from my child's healthcare providers or health plans about my child's health or healthcare. I understand that my child's healthcare providers and pharmacies may receive remuneration, or payment, for disclosing my child's information pursuant to this Authorization. I understand that Service Providers may be compensated by Sobi. The Service Providers will use and give out my child's information to (i) assist in my child's enrollment in Synagis Connect and to contact me on behalf of my child; (ii) assess my child's eligibility for the Synagis Copay Assistance Program, and (iii) assist with analyses of the efficiencies and performance of services provided by Service Providers. If my child is found eligible, I agree to my child's enrollment in the Synagis Copay Assistance Program.
In some instances, the Service Providers may de-identify my child's information and use or disclose the de-identified information (in individual or aggregated form) for any legitimate business purposes. I understand that the Service Providers will make reasonable efforts to keep my child's information private; however, I understand that once my child's information has been disclosed to the Service Providers, how the Service Providers further disclose my child's information may no longer be protected under federal and state privacy laws. This Authorization will last for three (3) years from the date of my signature or as otherwise required by state or local law, unless and until I cancel (take back) this Authorization before then. I may change my mind and cancel this Authorization by notifying Sobi in writing at SYNAGIS CONNECT, PO BOX 1989, COLUMBUS, OH 43216. I understand I may request a signed copy of this Authorization.
This Authorization Statement is governed by and interpreted in accordance with the laws of the state of Massachusetts, excluding Massachusetts conflict of law rules, and applicable federal law.

*By signing, I agree to be contacted by email at the address I have provided or to receive autodialed phone or text messages ("texts") at the mobile phone number I have provided for the purpose of helping me/the patient stay on therapy, which may promote or advertise Synagis. I certify that the number I am providing belongs to me and not a family member or third party. I understand that I may opt out of individual communications of the program entirely by calling 833-SYNAGIS, clicking the email link in a message received or by replying "Stop" by text to any text from Synagis Connect. Synagis Connect will not sell or rent this information and will use it only in accordance with this authorization and consent. Consent to being contacted by email, phone or text messages is not a condition of participation in the programs or the purchase of any products or services. I understand that my cellular service carrier's data and text messaging rates may apply. This authorization is valid for 2 years from the date the form is signed. If I am providing this consent on behalf of another person, I certify that I am authorized to agree to every element of this consent on behalf of such other person, and I agree that I will be liable and will hold SOBI Inc harmless in the event that such other person alleges that they did not give consent

*By clicking the submit button, I am agreeing that all information contained in this enrollment is complete and accurate

By clicking the submit button, I am agreeing that I have read, understood and will comply with the terms and conditions of the program and that patient currently meets all eligibility criteria.